functional testing for lower extremity rehabilitation

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R O B E R T C . M A N S K E , P T , D P T , M E D , S C S , A T C , C S C S

P R O F E S S O R

W I C H I T A S T A T E U N I V E R S I T Y D E P A R T M E N T O F P H Y S I C A L T H E R A P Y

V I A C H R I S T I O R T H O P E D I C A N D S P O R T S P H Y S I C A L T H E R A P Y

Functional Testing and Return to Sport for Lower Extremity Rehabilitation

Disclosures

E L S E V I E R S C I E N C E

H U M A N K I N E T I C S

I N T E R N A T I O N A L J O U R N A L O F S P O R T S P H Y S I C A L T H E R A P Y

R E H A B C H A M P I O N S C E

Reiman MP, Manske RC. The Assessment of Function: How is it measured? A Clinical Perspective. J Man Manip Ther. 2011;19(2):91-99.

Reiman MP, Manske RC. The Assessment of Function. Part II: Clinical Perspective of a Javelin Thrower with Low Back and Groin Pain. J Man Manip Ther. 2012;20(2):83-89.

Manske RC, Reiman M. Functional Performance Testing for Power and Return to Sports. Sports Health. 2013;5(3):244-250.

Davies GJ, McCarthy E, Provencher M, Manske RC. ACL Return to Sports Guidelines and Criteria. Curr Rev Musculosk Med. 2017; DOI 10.1007/s12178-017-9420-9

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Clinical Decision Making

ACL injuries common (350,000) ACLR

annually

Both short and long-term implications

Sugimoto D, LeBlancc JC, Wooley SE, et al. The effectiveness of a functional knee brace on joint position in anterior cruciate ligament-reconstructed individuals. J Sport Rehabil. 2016;25(2):190-194.

Heard BJ, Solbak NM, Achari Y, et al. Changes of early post-traumatic osteoarthritis in an ovine model of simulated ACL reconstructions are associated with transient acute post-injury synovial inflammation and tissue catabolism. Osteoarthritis Cartilage. 2013;21(12):1942-1949.

Risberg MA, Oiestad BE, Gunderson R, et al. Changes in knee osteoarthritis, symptoms, and function after anterior cruciate ligament reconstruction: a 20-year prospective follow-up study. Am J Sports Med. 2016;44(5):1215-1224


Extremely high re-injury rate

Multi-factorial

What are modifiable and trainable risk factors

Kamath GV, Murphy T, Creighton RA, et al. Anterior cruciate ligament injury, return to play, and reinjury in the elite collegiate athlete: Analysis of an NCAA Division I cohort. Am J Sports Med. 2014;42(7):1638-1643.

Risk of 2nd ACL Injury

2nd injury – 15% 8% ipsilateral ; 7% contralateral

Patients < 25 years

21%

Patients who returned to sports <25 years 23%

Wiggins AJ, Grandhi R, Schneider DK, Stanfield D, Webster KE, Myer GD. Risk of secondary injury in younger athletes after anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Am J Sports Med. 2016;44:1861-1876.

Risk of 2nd ACL Injury

Overall rate of 2nd rupture

4.5% ipsilateral; 7.5% contralateral

< age of 20

29% either knee

Returning to high risk sports

Increased odds of ipsilateral – 3.9 -fold

Increased odds contralateral – 4.9 - fold

Webster KE, Feller JA, Leight WB, Richmond AK. Younger patients are at increased risk for graft rupture and contralateral injury after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2014;22:1142-1148.


What are criteria used for clinical reasoning

and decision making for return to sports

Systematic review of 264 studies

105 (40%) failed to provide any criteria

84 (32%) time post op was only criteria

40 (15%) time and subjective criteria

35 (13%) objective criteria

Barber-Westin SD, Noyes FR. Factors used to determine return to unrestricted sports activities after anterior cruciate ligament reconstruction. Arthroscopy. 2011;27(12):1697-1705.

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Systematic review

RTS after ACLR – 7556 athletes

81% returned some level of sport

65% returned to pre-injury level

55% returned to competitive sport

Arden CL, et al. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med. 2014;48:1543-1552.


Increased odds of returning to sports

Limb-to limb symmetry – hop performance

Younger age

Males

BPTB Auto > odds of returning to sports

Hamstring > odds of returning to competitive sports

Arden CL, et al. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med. 2014;48:1543-1552.


Meta-analysis

55% return to premorbid level after ACLR

3 of 4 quantitative physical criteria

influencing ability to RTS are non modifiable

1) age, 2) male gender, 3) playing elite sports, 4) positive psychological attitude

Arden CL, Taylor NF, Feller JA, et al. Return-to-sport outcomes at 2 to 7 years after anterior cruciate ligament reconstruction surgery. Am J Sports Med. 2012;40(1):41-48.


Return to Sports…

Very few guidelines published

Few objective tests documented to support clinical

decision making process

Limited evidence to support our approach


How often do we have specific criteria that would stand up to:

1) Critical peer review

2) High levels of evidence to support decision making

3) Medico-legal critical analysis

Don’t Feel Alone!

• Almost 90% of the orthopaedic literature represents research findings from non randomized

study designs ranging from case series to prospective cohort studies

Obremskey WT, et al. Levels of evidence in orthopaedic journals. J Bone Joint Surg. 2005; 87A:2632-2638.

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Medico-legal!

• If a physician, physical therapist, athletic trainer allows an athlete to return to sports they may be

legally held responsible if the athlete encounters a serious injury!

Creighton DW, et al. Return-to-play in sport: A decision-based model. Clin J Sports Med. 2010;20(5):379-385.

Strength Deficits

Muscle strength deficits, and kinematic and kinetic deficits persist even after a patient has successfully

returned to sports!

Delahunt E, Sweeney L, Chawke M, et al. Lower limb kinematic alterations during drop vertical jumps in female athletes who have undergone anterior cruciate ligament reconstruction. J Orthop Res. 2012;30:72-78.

DeVita P, Horobagyi T, Barrier J. Gait biomechanics are not normal after anterior cruciate ligament reconstruction and accelerated rehabilitation. Med Sci Sports Exerc. 1998;30:1481-1488.

Georgoulis AD, Ristanis S, Moraiti CE, et al. ACL injury and reconstruction: clinical related in vivio biomechanics. Orthop Traumatol Surg Res. 2010;96:S119-S128.

Moraiti CO, Stergiou N, Vasiladis HS, Motsis E, Georgeoulis A. Anterior cruciate ligament reconstruction results in alterations in gait variability. Gait Posture. 2010;32:169-175.

Team Effort – Key Stakeholders

Individual patient

Patient family

Orthopedic surgeon

Physician

Physical therapist

Athletic trainer

SC specialist

Sports psychologist

Coaches

Importance of Testing

Evaluate rehab program and/or individuals

Is the rehab program working?

Strengths and weaknesses of program and/or individuals

Is the athlete ready for return to sport?

Data for research

Functional Testing Algorithm

Patients are initially stratified into activity levels:

General orthopedic patients

Recreational athletes

Competitive athletes

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Problems in Testing

Inconsistent rules and/or the way the tests are performed

“Cheaters”

Too many tests

Testing too often

Lack of “trained” testers

Testing Terms

Validity- does the test actually measure what it is designed to measure

Reliability- test/ re-test accuracy

Increasing Accuracy

Properly prepare the person to be tested1. Understand testing procedures

2. Ability to practice unusual testing aspects beforehand

3. Adherence to pre-testing instructions

4. Follow protocol exactly

5. “Trained” testers

6. Calibration of equipment

7. Consistent motivation from tester

Test Selection

Testing protocol?

Simple to complex

Single plane to multiple planes of movement

“Isolation to integration”

Environment

Age and gender

Soft tissue healing constraints

Test Selection

• Physician restrictions

• Personal physical characteristics

• Previous physical performance capabilities

• Sport specificity

• Metabolic specificity

• Must be safe, challenging, stress multiple planes of movement, be derived from fundamental movement skills, and should apply directly to a sport specific skill

Equipment Available

Weights

Benches

Stop watches

Jump equipment

Space

Flooring/ surface

“Toys”

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Test Administration

Warm-up

Consistency

Do not allow person

tested to record results

Motivation- helping person reach their full potential

Test Order

Physical characteristics

Power tests

Speed and agility tests

Strength tests

Anaerobic tests

Cardiovascular test

Testing on separate days?

Functional testing algorithm

Analysis

Involved/non-involved

% to BW, height, accepted standards

Previous test results

SD, Mean, Median, Mode

Basic Functional Tests

Patient reported (Subjective) measures

Tegner, SF36, Lysholm scale

Anthropometrics

AROM, PROM

Flexibility

Gait

Balance/proprioception/kinesthesia

Special tests- passive joint laxity

Anthropometrics

Use consistent and specific locations

Some common measurements: JL; 10 & 20 cm above JL, 15 cm below JL

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KT 1000/2000

Use of static ligament stability testing may be controversial for some.

Prefer to see < 3-5 mm side-side difference

Balance/Proprioception/Kinesthesia

Pacinian and Ruffini receptors, as well as GTO’s have been found in ACL tissue

Damage to neural tissue in the capsule, ligaments, muscles or surrounding skin is likely to affect afferent information available for processing at the CNS

Increased likelihood of re-injury due to inadequate restoration of the proprioceptive feedback system

Proprioception

Active repositioning-almost exclusively performed in non-

functional positions such as seated open chain extension (Harter et.al. 1992)

Balance/Proprioception/Kinesthesia

• Kennedy et al. (1982) suggested that proprioceptive loss after ACL injury contributed to increased laxity rather than being caused by the stretching effect of chronic increased laxity

Types of Balance

Static

Transitional

Dynamic

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Methods of Balance Testing

Static balance*single-leg stance*force plate, NeuroCom, KAT, FASTEX, etc.

Dynamic balance*same as static*Functional Reach test

Static Balance

Compare involved to non-involved

Time?

Testing equipment- ? force plate, Neuro-Com, KAT

Postural sway

Perturbation

Star Excursion Balance Test

Star-Excursion Balance Test

Tests all 3 planes of movement in 8

different diagonals

Goal is to force subjects to disturb their equilibrium to a near maximum

Star-Excursion Balance Test

Reliability = Moderate to High Manske and Andersen

Intratester = 0.94 to 0.98

Hertel et al


Intertester = 0.81 to 0.93

Kinzey and Armstrong


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M A N S K E R C , A N D E R S E N J . J O R T H O P S P O R T S P H Y S T H E R 2 0 0 4 ; 3 4 ( 1 ) : A 5 2 - 5 3 .

Test-Retest Reliability of the Lower Extremity Functional Reach Test

Purpose

To determine test retest reliability of the LEFRT

Determine differenced between dominant and non-dominant LE’s during LEFRT

Manske RC, Andersen J. Test –Retest Reliability of the Lower Extremity Functional Reach Test. J Orthop Sports Phys Ther 2004;34(1):A52-53.

Subjects

Sex Males

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Females

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Dominant

Extremity

Right 35 Left 4

Mean SD

Age (years) 24.7 3.8011

Weight (lbs) 153.175 30.6007

Height (in) 66.5750 4.1933

Manske RC, Andersen J. Test-Retest Reliability of the Lower Extremity Functional Reach Test. J Orthop Sports Phys Ther 2004;34(1):A52-53.

Methods

Balance on one leg while reaching as far as possible with other leg

Anterior reach

Anterior medial (45°)

Medial

Posterior medial (45°)

Posterior


Results

Anterior 45 Ant Medial 45 Post Post

Dominant .9346 .9515 .9342 .9681 .9547

Non-

Dominant

.9795 .9774 .9371 .9672 .9734


Results

Dominant X Non-Dom X Signifigance

Anterior 72.6325 72.5983 .972

45 Ant 80.2650 79.7094 .566

Medial 72.4017 72.5983 .853

45 Post 79.0256 79.2479 .706

Post 78.3846 78.5385 .830


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Eccentric Step-Down Test

Reps completed involved to non-involved LE

?? 50 repetition maximum

Set standardized protocol- height, reps, type of surface, etc.

No known reliability studies performed

Isokinetic Testing

Isokinetic resistance- fixed speed with a variable resistance that is accommodating to the individual throughout the ROM

Has been argued that limb position and speed of limb movement of testing are not representative of sporting functional movements (Lephart et al. 1992; Greenberger & Paterno 1995)

Significant correlation (moderate) between isokinetic strength testing and functional performance (Wilk 1994; Barber et al. 1990)

Isokinetic Testing

Methodology in studies is variable- making comparisons between them difficult

Gross et al. (1991)- measurement data could not be generalized from one type of isokinetic device to another (Cybex and Biodex)

Contralateral limb comparisons can be used as normative data or as a control if there is no precluding injury

Also can look at peak torque to body weight, Q/H ratios, etc.

CKC Isokinetic Testing

Considered more “functional” vs. OKC

Testing “integrated” motion versus “isolation” in OKC

“Weak link”

Lido Linea- good to excellent test-retest

reliability(Davies &

Heiderscheit 1997)

Normative Date for Isokinetic Testing

Outcome Measure

Unilateral Ratio:Ham/Quad

60°/Sec ~ 60%-70%

180°/Sec ~ 70% - 80%

300°/Sec ~ 85% - 95%

Descriptive Allometric Scaling for Isokinetic Testing of Quads

Outcome Measure

AllometricScaling

60°/Sec Males : ~ 90-100% BWFemales: ~ 80-90% BW

180°/Sec Males: ~ 70-80% BWFemales: ~ 60-70% BW

300°/Sec Males: ~ 45-55% BWFemales: ~ 30-40% BW

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M A N S K E R C , S M I T H B S , R O G E R S M , W Y A T T F . C L O S E D K I N E T I C C H A I N I S O K I N E T I C T E S T I N G : R E L A T I O N S H I P S T O F U N C T I O N A L T E S T I N G . I S O K I N E X S C I . 2 0 0 3 ; 1 1 : 1 7 1 - 1 7 9 .

CKC Isokinetic Testing: Relationships to Functional Testing

29 normal subjects with no history of injury

CKC isokinetic test: 3 sets bilateral reciprocal, 3 sets bilateral coupled

Velocities 10, 20 and 30 in/sec

Following isokinetic testing functional tests performed

Manske RC, Smith BS, Rogers M, Wyatt F. Closed Kinetic Chain Isokinetic Testing: Relationships to Functional Testing. Isokin Ex Sci. 2003;11:171-179.

Functional Tests

Bilateral vertical jump

Unilateral vertical jump

Double-leg jump

Single-leg hop

Single-leg timed hop (6m)

Mean scores of 3 attempts used


Manske et al

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BR-DL10 BR-NDL10 BR-DL20 BR-NDL20 BR-D30 BR-NDL30

Correlation coefficients for bilateral

reciprocal concentric isokinetic peak force

and single-leg functional test scores

SLHD

SLHN

VJD

VJN

STHD

STHN

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0.1

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BR-DL10 BR-NDL10 BR-DL20 BR-NDL20 BR-D30 BR-NDL30

Correlation coefficients for bilateral reciprocal concentric

isokinetic peak force and two-legged functional test scores

VJD

VJN

Conclusions

A significant relationship exists between CKC isokinetic tests and selected functional test scores

In at least 50% of these scores a moderate relationship exists


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“Functional” Tests

M A N S K E R C , S M I T H B S , W Y A T T F . T E S T R E T E S T R E L I A B I L I T Y O F L E F U N C T I O N A L T E S T S A F T E R A C K C I S O K I N E T I C B O U T . J S P O R T S R E H A B . 2 0 0 3 ; 1 2 ( 2 ) : 1 1 9 - 1 3 2 .

Purpose

To determine if a CKC isokinetic bout would alter test-retest reliability of functional tests that follow

Manske RC, Smith BS, Wyatt F. Test Retest Reliability of LE Functional Tests after a CKC Isokinetic Bout. J Sports Rehab. 2003;12(2):119-132.

Subjects and Methods

28 normal subjects

Velocity spectrum CKC isokinetic bout consisting of 3 sets bilateral reciprocal and 3 sets bilateral coupled

Same functional tests as described previously


Results

ICC’s between day 1 and day 2 for functional tests ranged from 0.91 to 0.98

Despite following a CKC bout, functional test reliability remains very high.


CKC Isokinetic Testing

Negrete & Brophy (2000) found significant correlations between functional test scores (single-

leg vertical jump and single-leg hop) and CKC isokinetic test scores

Low to moderate correlations (Manske 2003) with single and bilateral vertical jump test, double leg jump for distance, single-leg hop for distance, and single-leg timed 6-meter hop

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Standing Long Jump

For the propulsive phase- hip 45.9%, knee 3.9%, and ankle 50.2%(Robertson & Fleming

1987)

Indicator of explosive power- often use in strength & conditioning field

Standing Long Jump

Constantine and Sullivan: 38 Males; 7 trials; 30-40s rest = 0.99

Glencross: 85 males; Barefoot, best of 3 trials; 0.96

Manske et al, 28 subjects; mean of 3 trials; 0.97

Standing Long Jump

Normative Values

Females Males

90% of height 100% of height

Single-Leg Hop

Take off and land on same leg

Criteria for good jump

Index (Involved/non-I)

Only 50% of ACL deficient patients with c/o during sports showed a (+) deficiency(Noyes et al. 1991)

Single-Leg Hop

Bandy: 18 subjects; 2 trials; 2-5m; 0.93

Bolga and Keskula: 20 subjects; 0.96

Booher: 18 subjects; 1 trial; 0.99

Greenberger and Paterno: 20 subjects; 3trials D; 0.92; 2 trials ND; 0.96

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Single-Leg Hop

Manske et al: 28 subjects; mean of 3;

D=0.96; ND=0.97

Single-Leg Hop for Distance

Normative Values

Females Males

80% of Height 90% of Height

Jumping Comparisons: Segmental Contributions

Vertical Jump Horizontal Jump

Hip 40.0 45.9

Knee 24.2 3.9

Ankle/Foot 35.8 50.2

Biomechanical Perspective

Gauffin & Tropp (Am J Sports Med 1992) studied bilateral kinematic, kinetic, and muscular activation patterns at the ankle, knee, and hip joints during a 1-leg jump in subjects who were chronically ACL deficient

Results revealed similar involved and non-involved limb scores

Movement patterns and muscle activity patterns differed between injured and non-injured limbs

ACL deficient- greater flexion angles for the hip and knee joints at touchdown; also a reduction in EMG activity of quads while hamstring activity remained similar

? Improved capacity of the hamstrings to control anterior tibial sheer during landing

Rudolph et al(Knee Surg Sports Traumatol Arthrosc. 2000)

looked at “copers”, “non-copers” and normals

Reported very little difference in kinematic, kinetic, and EMG variables between copers and normals

Suggested copers used more contribution from the hip in maintaining support vs. normals

No differences in VGRF between copers and controls

Non-copers hopped differently- less knee flexion during ground contact and had lower peak VGRF

Non-copers also had greater contributions from the hip and lesser contributions from the knee during the transition from weight acceptance to hop propulsion

Conclusion- comprehensive assessment that includes the analysis of kinetic, kinematic, and EMG data to thoroughly describe the biomechanical and neuromuscular profiles of the stable and unstable lower extremity

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6 Meter Timed Hop Test

Single-leg timed hop over distance of 6 meters

Encourage large, forceful 1-legged propulsive hop the measured distance (Wilket al. 1994)

Propulsion-deceleration-propulsion, etc.

6 Meter Timed Hop Test

Bandy: 18 subjects; 2 trials; 2-5min; 0.92

Bolga & Keskula: 20 subjects; 3 trials; 40s; 0.66

Booher: 18 subjects; 1 trial; 0.77

Manske et al: 28 subjects; mean of 3 trials; Dom 0.92; ND 0.96

Triple-Hop For Distance

Three consecutive hops on one foot in a straight line direction

Encourage 3 maximum distance

Triple-Hop For Distance

Riseberg: 21 subjects; mean 3.9weeks (1-7); difference in distance recorded;D=0.92;ND=0.97

Single-Leg Cross-Over Hop For Distance

Three consecutive hops on one foot crossing 15 cm marking strip with each hop

Encourage 3 maximum distance hops

Limb symmetry index

Maximal Controlled Leap

Test of force absorption (Juris et al JOSPT 1997)

Leaping is the projection on the body from one limb onto the other

Testing grid- 1.91 cm wide, 3 m long, and marked at 10 cm increments

Hop and stop test involved a maximal hop for distance and a maximal controlled leap

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Force production- maximal hop for distance

Constraints of hands on hips and not allowing swinging the suspended leg

This eliminated movement strategies involving leg and arm swing

Measurement at point of contact of hopping/leaping toe

Hopping distance was normalized to the subject’s stature vs. absolute value

Maximal hopping distance from each limb divided by the subject’s height (both in meters), x 100

Force production symmetry = larger hop/smaller hop

Stop symmetry = larger stop-to-hop ratio of the two limbs into the smaller ratio x 100

Data suggest this protocol does accurately assess functional and dysfunctional knees, and that force absorption may be more critical than force production in determining functional capacity

LEFT Test

Dimensions (30ft. long by 10 ft. wide) designed base on clinic space constraints

Negrete & Brophy (2000) demonstrated correlation of the LEFT test with other tests to measure performance

Quantity and quality of performance evaluated

Very stressful to the anaerobic CV system

May need to consider age, fitness level, sport,etc

LEFT Test

1. Sprint (forward)

2. Sprint (retro-run)

3. Side shuffles (both ways)

4. Cariocas (both ways)

5. Figure-of-eights (both ways)

6. 45-degree angle cuts (outside foot) (both ways)

7. 90-degree angle cuts (outside foot) (both ways)

8. Crossover step (both ways)

9. Sprint (forward)

10. Sprint (retro-run)

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LEFT Test

NORMS

Males Females

90 sec-good 120 sec-good

100 sec-average 135 sec-average

125 sec-below average 150 sec-below average

BUT IS THIS ENOUGH?

ACL RECONSTRUCTION

Schmitt LC, Paterno MV, Hewett TE. The impact of quadriceps femoris strength asymmetry on functional performance at return to sport following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 20012;42(9):750-759.

Impact of QF muscle strength asymmetry at time of return to sport on self-reported function and functional performance of individuals following ACLR


55 ACLR who were medically cleared to return to sports

35 uninjured control group

QF strength MVIC

Quadriceps index (Involved strength/uninvolved strength x 100%)

ACLR group further divided into 2 groups based on QI

High QI >90%

Low QI <85%

IKDC scores

Hop Tests


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ACLR group weaker

ACLR group reported worse subjective function


ACLR group worse on hop tests than Control

LQI worse than HQI and Control

Hop test performance not different from HQI and Control

Strength predicted performance on hop tests


Examine clinical utility of FPTs with patients < = 1 year PO.

Systematic review using PRISM guidelines

12 studies included for analysis

Of 12 articles 41.7% used as outcome measure

58.3% used as measure of function

None utilized FPTs as measure to determine readiness to return to sports

Narducci E, et al. The clinical utility of functional performance tests within one-year post-ACL reconstruction: A systematic review. Int J Sports Phys Ther. 2011;6(4):333-342.

Develop and enhance a useful checklist type tool following use of Delphi study

Delphi technique series of survey or questions to experts by controlled feedback to obtain reliable consensus of opinion in timely and orderly fashion

Haines S, et al. Development of a physical performance assessment checklist for athletes who sustained a lower extremity injury in preparation for return too sport: a Delphi study. Int J Sports Phys Ther. 2012;8(1):44-53.

Haines S, et al. Development of a physical performance assessment checklist for athletes who sustained a lower extremity injury in preparation for return too sport: a Delphi study. Int J Sports Phys Ther. 2012;8(1):44-53.

Functional Performance Testing

Testing for outcomes can take many forms

Self reported measures

Impairment based measures

Physical performance measures

Use of cluster

Use of continuum of tests

FPT algorithm

Reiman MP, Manske RC. The assessment of function: how is it measured? A clinical perspective. J Man Manip Ther. 2011;19(2):91-99.

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Common Themes in Literature

1. No consensus on which specific tests should be used

2. Quad deficits, particularly force development quickness appears to be critical factor in RTS

3. Hop tests appear to have some predicative ability for future performance

4. There should be a battery of tests assessing strength, power, laxity, and “fear”

5. No published studies have good predictive ability for RTS

Conclusion

No one specific type of testing, or specific “functional” test has been proven superior

Most authors agree that a comprehensive, systematic evaluation of the athlete is necessary for the most successful return to the athletic arena

Does the test battery determine dysfunction?

Step by step testing with successive advancement protects not only the athlete but the clinician as well

The best testing may be actually “breaking down” their specific sport and position in that sport

Thank [email protected]

@robptatcscs

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mailto:[email protected]

functional testing for lower extremity rehabilitation

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